Provider Demographics
NPI:1871399451
Name:MANNON, JACLYN RICHELLE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:RICHELLE
Last Name:MANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1235
Mailing Address - Country:US
Mailing Address - Phone:304-453-2800
Mailing Address - Fax:
Practice Address - Street 1:540 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-8503
Practice Address - Country:US
Practice Address - Phone:304-633-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF2764273747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant